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NECTQR IONDQNO C3wner AI.L PNASE ENTERPRiSES ��ntractor
� 1665 NE 1C14 ST IAZARO FERRlAND�Z
Mame:7�62Q85518 SANCNEZME48�a YAHQO.COM �025 SW 26 ST
SRNCNEZNiE48 c�r YAHOO.GO�r1
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° !ns eettan R� uests
� Deseript�on:ftEPAiR METEft FP� �� V�luatian: $ 5E)0,00 �
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� T�talSq Feet: Q.QO
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Fees ,0.mount I�ayments Date Raid Amt Paid
Applieatian Fee-�ther $50.00 T`Ota1 F��S $116.30
CCF $0.60 CaSh 1Q/22/2021 $yp,p�
DBPR Fee $2.00 Credit Casd 10J26�2Q21 $66.39
I�CA Fee S2.QQ
Education Surcharg� $p.�p �����t Due: $4.Q0
Permi�Fee $SO.OQ
Seanning Fee $9.00
TechnofogyFee SZ•SQ
T�tal: $516.3Q
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In consider�ti�n of fih� issuance t� me of this permit, ! agr�e to pe�form the work eovered hereunder in compiiance with alI ordinances and eegui�tions
p�rtaining thereto �nd in strict conformity with the plans, drawings, st�4ements or specifications submitted to the propee a�thorities of Miami Shares
ViI(�ge. In accepting this p�rmit I assume eesponsibility fc�r al!work done by either mys�If, my ag�nt, servanfs, or empiayes. I unders4and that separat�
permits ar�r�quired foe�LECT'RICAL, PLtJM�ING, (VIECN�NICA�,WINE}QWS, DOC}RS, FtQQFENG and SWIMMIN�POO�w�rk.
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C7WNERS RFFIE} �`iT: I cert that all the c�egaing informatior� is accurate and that ail work wili b� dane in eampliance with ai! applicabie laws
r�gula4ing constr c:€ien�nd ao ng. Futherm re (auth�rize the above named conte�aetor to da fhe wark stated.
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O�tober 26,2021 P��e 2 0$2
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10050 N.E.2nd Avenue,Miami Shores, Florida 3313� ���� �
Tef:(3Q5)795-22t�4 Fax:(305j 756-8972 ��
tNSP�C'�IC3IV IENE PHQNE RIUfViBER:(305)762-�949 � �`�
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�� � Mast�r Permit N�. ��-: T� �� � x�`� � �-��' � ��
�� (.� �� Sub Permit �lo,
��ur��i�� ���c���c � fto����v� � �Evis�o� � Ex�rE�sio�v �����w��
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CQNTRACTOR DRAWlNGS
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1Q�AQDRESS: ' �°'_,�� � �. ��,...;_ t` .,.� �`� �..µ., ..
Citv: Miami Shores Cauntv: Miami Dade Zip:
FoliojParcel#e .��P ��.��' � �'��'� �� �� Is the Buildin�Histaric�lty Designat�d:Yes NO
C}ecupancy Type: �oad: Canstructian Type: Flood Zone: BFE: FF�:
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OWNEEi:Name(Fee Simple Tifleholder): �� � i ����'� � �_ '�����'`' ��� �`� Phone#: �� ` � � �` ` ��" `�' � ' �
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Address: � ` -,�� �`,' �:� �`���a,��'.`� �
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Gity: � ` 0 , ��t����y t � �'��'���� � SCate: ��� Zip: ����' ° �``��
Tenant/�essee Name: Phone#:
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C�NTRAC�'OR:Company Name:�������.�� `�� � : �.��.�, e�r,�� � ..!', �„ Phone# �<�i, . M� � �. ;� "3 ��,��
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Address � � {. ..�. �` i• ��� � ,�_�, ,°�
City: �.� a �� � State:� ��=r' Zip: .�'� �� t � �.
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Qualifier[Vame: .�� �� � �' `'� � � � �
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State Certificat�an or Registration#: � ��:.k- _� ���t� s� ���� �� Certificate of Campetency#:
�ESlGRIEft:ArchiteetJEngineer: Phone#:
Address: City: Sta[e: Zip:
Value af Work for thts Permit:$ ���� SquareJLinear Foata�e of Work:
Type of Wark; ❑ Addition ❑ Alteration ❑ Rlew � Repairjfteplace ❑ Demolition
C}�scription of Work: ��, �� � ��� �`�°��`.��� ��� �� �'�'��°°
Spec�fy color vf�c�lar thru �i�e:
SubmEttal Fee$ Perrrtit F�e$ GCF$ CQjCC$
Scanning Fee$ Radan F�e$ DBPR$ Natary$
Technolagy Fee$ Training/Edu�atian F�e$ Double Fee$
Structural Reviews$ Bond$
TC}TAl fEE NqW QUE$ �� � �C�
(Revised02J24j2014)
�onding Company's Name{if applicable}
Banding Company's Address _
City S�ate Zip
Mortgag�Lender's Name(if applieabfe}
Martgage l.ender's Rddress
City State Zip
Application is hereby made to obtain a permit ta do the work and installations as indicated. 1 certify that no work or installati�n has
commeneed prior ta the issuance of a permit and that all vrork will be performed to meet the standards of all laws re�ulating
canstruction in this jurisdictian. I understand that a separate permit must be secured far EGECTRIC, PIUEVi�ING, SIGNS, PC}QLS,
FURNACES, BQILERS, HEATERS,TANKS,AIR CONDITIONERS, ETC.....
QWNER'S �FFIt�AVIT: 1 certify that al! Ehe fore�oing informatian is aeeurate and that all wark will be done in compliance with all
applicable laws re�ulating canstruetion and zoning,
" ARRiIN� T� QWNE�a Y�UR FAILURE T� RECORD A Nt?TICE QF COMMENCEMENT MAY
RESUCT IN YaUR PAYING TWI�E FQR iMPR�VEMEN`fS T'A YQUR PROPER . IF Y�U INTEND
T� Q�TAIIV FINANCING, CONSULT WITH YOUR LENDER tJR ,�N A O�RIEY BEFQRE ���IJRDING
Y�l1R Nt7TI�E OF C�MMEN�EMENT."
Notice ca Applreant: As a canditian to the issuance af a burtding permit wrth can estimated value exceeding$2500, the apptictrnt must
pramise in good faith ihc�t a cvqy of the notice af cor»rrteneement and construetic�n lien !aw brc�chure will be delivered to the person
whose property fs subject to attachrrrent. A(sca,a certif+ed�opy of the recorded notice�af cor»rrreneement mus[be posted czt the jab site
far the first inspection which oecurs seven (7J dvys after.the bcailding permit is issued. in the absence of sueh posted notice, the
inspecfr`on vurtt not be approued and a reir�s��ction fee� ` be eharged.
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Si�nature � Signatuee
CONTRACTOR
The foregoing ins°trument was acknowledged before me this The faregaing instrument was acknawledged before me this
� day of ��� "����-�` , 2Q �'� , I�y �`� d�y of �-`�--m .-� , ..� ,�� � , bY
��.�`��� ���"l���1°� ,�uho is persQna!(y known to �� ��� ���'��"1�����ti�o is personally known to
m�c�r who has produced ��- � �'� �--- as me or who as
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identificatian an tir� � tak��6�1�.�€��°t�� identifieati a�` di���r#'�E��
Lili�n��P,I��r�� p t�y�c��r�,rzn r��a t��3t�
NATARY PU�L! . �� t�y C s�mrv,ias�cm wk�o�3t�s NOTARY P I��e.� ��p"�s t92ra5t2t�25
�, ���� �xp�r�s f}�Ii 5t2Ct25
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Si�n: & Sign:
Print: � � � � �� <'1 �.� � ���ld�°� f"`f.'. � Print: �°1�C��"1 e�, �'`�, e��s.,��' -�-�,.
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Seal: Seal: �,�� ���ry�U��,c����� f. ,��
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APPROVED BY ��� � � ���..�Flans Examiner Zoning
Structural Review Clerk
(RevisedQ2/24J2014�
Prop�rty Search Applie�tion - Miami-I��de Count}j Fage 1 c�f l
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�ener�t�;d On: t4112f2021
Pro��rty Er�fc�rmation . ,.�� � � _ °° �,'
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Folica; ;11�2232-032-0200 � ��`� � �
_ �.� _ --.-�_ �1&65 N� 164 ST _ .__ , �
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Prapea�fy Addr���: €Miami Shores,FL 3313�-2667
_�_��_.�.�,� �,_�.��.__�..� �.._.� __
O�vrner ff�ECTOR LONDONO
jMf�RIA SANCHEZ
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w_...�_.,_m_m�._._.__�___�__ ,_� �_.A_�..__.�__._.___.�___�...___.w_._.__.. __._
[1�ailing�ddress €1666 NE 104 ST � �' �� � ' �r, ,�
�MIAM(SHORES, F�33138 USA �''� ���,� :
__ � � _ ._�.__._�__ � __m___ �..__ ,
PA Rr6mae�r,�c�ne OQ SGL FAMI�Y-28Q1-3QOQ SQ .�����
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_.._�n�______�. �_._�_.��.��� ��__�a.�_.
�rimary t�andUse �61�1 RESIDENTiAL-SlNG�E :; � �
i�AMILY: 1 UNIT
;
Beds!�ath�f Natf �mm��� ;2/2(U___.�. e.�.�________�
�.��� ����_.__.____..._______._� �.__m
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Flaors___ .__m��. � �
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Living li�it� E� �,
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A�tu�Il�rea ;3,962 Sq.Ft � �e�� ` '
�Pving Ar�a � ?1,9��Sq.Ff .�.�.�_.�.�. �
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� __.._��._._...� _�_____._.� _._.____.._..._.._...._.._.._�.._._.._....�.. ._ Taxa�l�V�lue Informatior�
Adj�sted�tc�� ;2,3�2 Sq.Ft
� �. ����� � 2Q21; 2020i 2Q19
�.QtSize €8,440 Sq.Ft � _�___ �_�__ _e�__ __. .��a_ � �n _�i____.____.� ___
YearEtuilt �� ���.954 � Gounty
, ________ _.__h_n. � ._.__ . ��._
Ex�*mption Value �w50,QOd $50 000� �50,000
� . ...... � _�___._____.___ __ __._ _
Ass��smen#Inf�rt�ation Taxable Value ! $�27,600i $833,644� $83�,TQ4
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_�___ .___�____�._�...� __._.�__�_��w__u_�. z_ ._...._r_...�..�_
Year 2021 2020� �019 Schoof�oard
_.�._ _ __ _ _._ _��� _ � ___�. _. _�___ _ ,—�.__ .__��_.�_.�m_______-.-
__�____
I�and Va6ue j $449,150� �449,15d; �449,15Q �xemp4ion Value I �25,QOOi $25,QOQ $25,OOd
__. � __-____w__��.�� �_ __r �.k.
��._. .�f___.._.,�____ � � _ �..____.. _.._.�.r.._._...�_.._...._ .. � �_ _______..�.__ _, r
�utldEng V�lu� € $425,1�7i �430 1$9� �43�,191 T�xabl�V�Eue � $�52,64t�; ��5�,644� $863,704
�_���__m��,.�..�_ �..�
m�m��M��_ _����__ �__�._ m__.____�...n _._.__________._.�_.._�._.._..._.�. � �._�__t .___...� ��e
XF Value � �3 263� $4 3051 $4 363 Gity+
_._________.___..________..�.___ ___. _.. , __.__..�____.__._.
��� �_�m ��_mm__ �..._mm�_�_�. � �� � _._�_� � ��� .��.�..
ltRark�t Va1u� $�77,600j �8�3,644 $888,7Q4 Exempti�an Value i $50 OdO, $50,40Q� �50.00�
�� _ __�_ . �__��_.� ����. �
_ww�.__ � ___� �_.__ �.�,.____._�__._ T�x�b(eVaiue i $827,6Q0; �833,644� $�3�,704
�_�__.�� � � �
Asst�$s�dYaEue � �877,600= $$83,644� �$�$,704 , I
��_���_��.__�.�.� m _ �_.�_
Regic�nal
_._.v_.�.�..v._.__ ._.�_m____� �-a- ;--___.�___...__.._;___._.�_,.�_.�_
�en�fits Op�fo atian Exemption V�lue � �50,oQ0� $50,(3Q0� �5Q,QOa
��nefit �Type � 2021 2020� 2Q19 Taxabl�V�lue _��� _�827,60fl; �833,64����$�3�,70A
�.� �_' � ___.__�.__� �.��_m�
Horrt�st��d �mptio� �25,000� �25.Q00� �2�,Q4�
�__�__�.�__�_._�_�________���_ra_____.__�
� ._.e_A__�__. ._��.__.. S�les Infe�rm�ticrn
Second Hom��t�ad i�xempti�n ` �25 000, $25,006 $25 Of�O
, � _ �
____�_.��_.�_. ___.�,_.... �. _� .._� ��_� _�_ J ._ ___. ,
Note: Not ali benefits ar��ppiicable to alE Taxable Vaiu�s(i.e.Gaunty, Pr�viaus Sale ! Price; OR�o�k-Page � Qualification Description
.��.�..._.
Sch�ol�oard,Gity, R�giona!). Q7t1(}12Q18 � �1,125,000� 31075-3000 �Quai by�xar�r of deed
_,m____._____.__..�____.
0519312008�= $�54,000� 26619-1779 Sal�s which�re quaiifi�d
Short�eg�l Description --�-�---���- ----� _� �_�_ �ae_� .�_
0910112(303 ; �520,000� 21645-2693 Sal�s whieh are qualified
RIVER�AY PR(�K AC7C�N P�40-72
LOT 21 BL{�3
LOT SIZE IE�R�CU�AR
GOG 21645-2693 Q9 2003 4
The Office af Ehe Property Appraiser is continually editing and updafing the tax roll.This wet�site may not reflect the mast eurrent inPoemafipn on record_The Peaperty Appraiser
and�Fliami-Dade County assum�s no liak�ility,see full disctaimer and User Agreement at http:!/www.miamidade.geaviinfo/disciaimer.asp
Version:
lzttp�:Ilu=ww.miamid�d�.�ov�A�pstPAlprc�pert��se�-ch/ � I(l/12/20�1
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'�� ��``�= Ron DeSantis,Governar Naisey S�shears,Secretary
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TNE ��E�TRICAI. GC��ITRACTC}R NEREIN 1S CERTIFIED Ui�C3ER TNE
PRC��tISI(��S �3F �:NAPTER 4�9, FI..C�F�IC�A STAT'tJTES
Additiean�l Busir��ss Qu�li�ic�tic�n
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ih[s Looa7 Bus"aness Tux fiea»ip2 only cor�#�rms p�ymeni of ths l.�cal��2aistes�7ax.Th�a f4ecai�tt is nn4 a ficesns€�.
�ermit.or�ce�i"sf"sc.ak3on c,4 tite hnld�,r s qu�Iifice#ir�r�s,io drs busiz»ss. Ncsidor musi comp3y v�4tt�any gouem�naasY�l
t�r nongo�rsrn��n4�1 re�gulatorp iz��us�ad a�t�uirem�nts u�rtfsets apply to 41ke busiet��s.
Ttra SiECE?PT htQ,a4wva must ba Gisplapsd on aII�rrmm�rcf:s!v�fiicl�s-Pr�iarr�i-Dad�Cade Sec�a-Z76_
�s�rmr,�r�infarmaticrra,uasi£wwy r»�amida�#�gov�,jtaxG911�r4ar '..
.�� i2 � � . G�t�TIFIGAT � F L.1�4 I�ITY lN �U A �E °�'�`��`°°"��"
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THIS GERTIFICATE I5 lSSUE�AS t�MEATT�R C3F iNFQRft+IATtON t?NLY AND GCINFERS NO RfGHTS UPQN TFE�C�RTEFIGATE HQ�DER.THI�
CER`fIFICAT�Dt?ES NC?T AFFIRtt�ATlV�LY OR NEGATIVE�Y AMEND,EXTEN�CIR,AL7ER TH�CQVE G�AFF(}R�ED BY TNE Pt?GiGlES
BE�OW. THtS CERTtFICAT�OF IN3U�ANCE DQES NOT CONSTITUTE A G�N7RACT BETVYEEN TN�tS�U#NG iNSl1RER(S),AE�TNORE2E0
REPRESENTAT6VE OR Fi20�UCER,AND THE GERTf�IGATE HC)LDER.
IMPORTANT: If the certificate holder fs an ADDtTIONAE.INSURE[�,the palicy{ies}must have ADDITlONAL INSURED provisians or be endorsed.
If SUBF2C?GATIC}N 18 WAIY�D,subject to the terms and conditions of the poticy,ceetain policies m�y require an endarsement. A stat�ment on
th�s certificat�does not eonf�r right�t�the eerEifleate holder in Iieu af such endorsement{s)�
n�ooueeR c rvTncr Georgina Bianca
NAME:
CaSUalty�ySt@IT15,InC. PffONE (305)551-Q69Q FAX (305)551-Q857
/C o xt: A/C No:
3331 SW 1d7Ave E-�ai� eor ina casuaif s s4ems.com
ACIDRESS: 9 g � Y y
lNSURER(S}AF�ORDING COV�RAG� � NAIG#
Miami F� 33185 ��SURE��, Granada lnsurance Company
INSURED INSURER B;
Ail Phase Enterprise Ina iNsuRetz c:
3021 SW 16th ST i�suReR o:
INSURER E:
MIAMI FG 33145 INSURER F:
CQVEi2AGES CERT"IFIGATE NUMBER: ��.Za102306644 REVISI4N NUMBER:
THIS IS TO CERTIFY THAT THE PQ�ICIES OF INSURRNCE LISTED 6ELOW FiAVE BEEN ISSUED TQ THE iNSURED NAM1IiEC}ABC7VE FQR THE PO�ICY PERIdD
WDiCATED. NOTWITNSTANpWG ANY REQUIREMENT,TERM OR GQNQfTION OF ANY CQNTRACT QR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUEQ OR A�AY PERTAIN,THE iNSURANGE AFFORDED BY THE PO�ICIES QESCRlBEQ HEREIN IS SUBJEGT TO ALL THE TERMS,
EXC�USIQNS AND CONQITIONS QF SUCH PQ�ICIES.LIMITS SHOWhi MAY NAVE BEEN REDUCED BY PAID C�AIMS.
���'R TYPE QF Ih1SURANCE POIICY EFF POGECY EXP
LTR IP! D WVD POUCYNUMBEI2 MMlDDlYYYY R9M/DDlYYYY LIMITS
� COMPAERGiAl.GENERALLIABII.Ifl EAGHpCCURRENCE � �.000,000
" Too,aoo
CLAIM&MADE �C�GCUR PREhhISES tEa acc�rrence S �
MEa EXP(An one personl $ S�Q��
A 01�5F�00146955 9012412020 1Q12�412021 PERSON��&�DviN�uRY S �,OQ0,000
GEN'IAGGREGATEUMITAPRLiESPER�. GENERALAGGREGATE � �,d40,Q00
� PQL€CY �PR4- � � 2,OOd,00Q
JEGT �C PRqQUCTS-COMPr6PAGG $
t}iHER �
AUTOMOBI�E l.IABIUTY COM8INED SINGLE�IMlT �
-�a accident �
ANYAUTO 60pilYINJURY(PerRersonj S
._..___._..._..............
OWNEQ SCFiEDULED �QDILY lNJURY(Per accident) S
AUTQS ON�Y AUTOS _,,,�
HIRED NON-OWNE6 PROPERTY QAMAGE �
AUTQS ON�Y AUTOS ONLY Per�ocident
S
UMBRELLA LIAB aCCUR EAGN OGCURRENCE S
EXGESS�tAF3 CUiiMS-flAADE riGGREGATE S .� .
DED RETEtiT!QN S S
WORKERS COPAPENSATiQN PER OTM-
AND EMPlOYERS'�IA6EGITY Y r N STRTUTE ER
ANY PRORRIETQft?PARTNERtEXECU'fIVE � �j� E.�.E.ACH RCCIC1ENi �
QFFICER'MEM�ER EXCLUQE6? °'�'
(Mandatory in NHj E.�..piSEABE-EA EMP�OYEE 5
If yes.descrlbe under
DESGRIPTIQN 6F OPERATtONS belQw E�.C)IS6ASE-POUCY LIMIT $
DESCRIPTIQN OF OPERATIONS t LQCATION5 t VEHIG�ES (ACORD 105,Additional Remarks ScheduEe,may be attached if more space is r�quirad}
C�de 02478 IEEeetrica!Work insidelautside bldg
LiC.EC 13d09723
CEi2TIFiCATE HQLDER CANCELLATIQN
SHOULD ANY 9F THE A�t?VE DESCFti�ED POCICIES BE CANCE�LED�EFORE
THE EXPIRATION DATE THEREOF,MOTECE WILL BE DELIVERED IN
Miami Shores Viliage AGCORDANCE WITH TtiE POUCY PROVISIONS.
1Q�5Q NE 2ndAve.
AUTHQREZED REPRESENTATIVE
Miami Shor�s FL 33138
Q 19�$-2Q15 ACORD CORPORATiON. Ail rights res�roed.
ACQRD 25(2016t03) The AGORD name and Iogo are registered marks of ACQRD
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J4�1tv1Y P�.TRONIS
GHIEF FINRNCIAI.OF��C�F? a�'��'T'�C)F F�.��fL�l�
C��F'#�F�Tk�I��lT C��F11���i�1�.L���Vf���
C�61�t�lt�t� t�F 1tVC}��C�f2�'�����N�AT°lC3N
*���Rl"IFt�AT��F �L.�CTI��! TCJ�� �X�iVIPT F�t�IVI FI�C?RIC}A WC?�K�Ft�° ��l�I�ENSAT'6t�N L.�W**
C�f��T�UG�`IC�N lN�U�1"R�° �X����'IC?PI
This cerfiifies that the individua! IisEeci below h��elected ta be�xempt fram�Ic�rida Wc�ekers'Cc�mp�ns�tic�n I�w.
EFF�C�'IVE C�t�T�: 7/27/2C}2(J E?C�tRA1"6AN ��T'�: TJ27f2Q22
P���C?N; �A�ARO F�RNA�lDEZ EP�A(!�: JNQRTAF'La��EI�LSt�t�TH.NE�i'
F�tN: 383927QT6
�USiNEB�N�IM�APl�ADDF2�S5:
AL.L Ph{d��E ENTERPRISE� INC
302�SW 16`�H ST
fVl{RMI, F�.33145
SCC3E��f)F Bl1SIN�SS�R�'RAC��:
ESectrieai Wiriny Within
0uiidings ar�d€3eiver�
IMRORTANT:Pursu�nt ta sut�section 4Af�.E�S{i A),F.S.,an o(fi�csr'af a coeporatiof�who r�i�cts exarngtion Fram this chapker by filing a certificate af eEecfion ucidee
this section may�Q[r�covec b�ne6ts ae com�ensat[on unde€ihis chapter.Pur�u�nt ta aubsection 440,Q5(12�,F,S.,Ceetificatea aP efectian to be exempt iss��ed
under subsection(3)shall app{y or�fy to the corpprate o�c�r namecf on the notice of ek�ction tQ b�ex�mpt and aA�IY cznfy within the scape Q€ti�e business a€
irac��liaked on the nafic�o�eleeFian to be exen�pt.Pursuant Eo subseetion 44f�_Q5{13),F.S.,nokic�s oP electi�n to i��exempE�nc#e��tificates o�electian to b�
�x�mpf shafi be subject ko revocatian i€,at�ny tinl�after the iiling oi the��otiee or the issuanee of the eerti�cate,the persc�n nam�:ct on th�nc�tice ar c�rtiFi�ate
no Ionger m�ets the requiraments o�this sectia€�for issuanee e�f a certificade.The de�aartn��nt aha�[revake a Gertificate at any time€car iailur�af€he persan
named on th�certificate ta meet the requirements o�t1�is saetio€t.
[��S-F2-G�WE;-25�GERTkFIGATE C��EE�CTtC?N TQ�E E�C�hlIPT�tEVfSEa C18-13 EQ12Q1310 C�U�STlC}NS`I(85Q�413-1609
��� �t��es,� ��r����is�s ��.�:,:
30,?1' SW 1f.`'`' S,t
(\!Ii�ar��i, F� 3�1�5;
Zo/�z12a2�.
stafi� of Florida
Caunty �f �Vliami Qade
Bef�re me this day personally appear�d l.azaro Fernandez who, b�ing duly sworn, depases and
s�ys:
That he or sh� is will be th� c�nly pers�n workin� c�n th� projeet located at:
1665 NE 10� Stre�t, Miami She�res FL 33���
C�ntractc�r Sigr�ature
�1�,
Sworn te� (or �ffirmed) �nd subscribed before m� thi day c�f � , 2Q21
�y �,�� �1��
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r. b � �y G� �t4ht�93994
�e� Expt 02t95t�425
P2CSOt1d0�tf Kt1CJW
Or produced identification
Typ� of Iden�ific�tion Prod�aced
�
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� � iami hore� illage
.��� ���.�� 1� 1
�'� ��� 100�o N.E.�►,a a���,��
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Miami Shores, Florida 33138
Tel: (305} 795.2204
F�x: {305} 756.8972
otice to wn r � rker ' en tion Insur nce e ti n
t l<.�2 ,Z � t t.�. � i lt., \ ti ��.t t :".�v �� �;. { ` ��t t,..
�Z 1. � �1�� •tt }�\ i i�� Z tit � j � \`, �� .}��� i ti\ 6t :\� 1\ti �l �lt �i����� l 1.� � { a\:� '.,
„t,.'��,�. .�r, ct..,�����,., ,� ,�5�� ..,,1i£ �a 1� .:1�� t ���1�a �,�is�.E\„ A„ .t,.
Florida Law reqt�ires Worlcers' Compensation insurance eovera�e c�nder Chapter 440 of tl�e Floi7da Statutes, Fia. Stat. � �40.05
allows co��porate afficers in �he constructian i��dust�-y to exempt tl�emselves fram this reqUiren�ent fo�-at�y constr�etion prajeet p3-ior to
obtaii�it�g a building permit. Purstzant to tl�e Florida Divisian of Workers' C�Tnpensation Employer Faets l3rocl�ure:
A�� employer ir� t1�e eot�st�-uetic�t� industry �ilio emplo}�s one or more part-tiz��e or full-time
employees, i�lelE�dinQ the o�vner,must obtain wc�rkers' compensatio�i eoti=erage. Corparate offiee�-s
a�- memt�ers of a li�nited li�b�lfty cotr�}�any (LLC} in the const�-uction industiy may elect ta l�e
EX�ITl�?t If:
1. Tl�e officet•awns at least 10 percent of the stock c�f the eotporation, ar it� the case of
an LLC, a staeetneut attestinb to ttle ininimum l 0 pereent a�vnershi�;
2. The officer is listed as an offieer of the corporation in the records af the Florida
C3epartmenE of St�te, Divisi€�n of Cotporations;and
3. Ti1e cc�rparatian is registel•ed and listed as acti�=e �uitl� tlte Florida Departme��t of
State, Division of Coipai-ations.
Nc� more than tt�ree coiporate officers �aer eorporatic�n or limited liability eor��any n�ei�lbers are
�Ilo�ved ea be cxempt, Construetion exeil�ptions are vaiid for a �aeriod af two years or untit a
��alutlta�-y re��ocat�on is tiied or the exemption is�-e�Toked by t}�e Divisiot�.
Youf-cant�-actor is requestin�a�er�xlit under this�varkei-s' cotnpeflsatiot� exemption and l�as aeks�o�vled�e that l�e c�r slie will not use
day labor,�art-tinze employees or si�bec�ntractars for��our prc�ject. Tl�e cay�tractor has�rovided an aftidavit stat3ng that he or s}�e ti�ill
�e ti�e anly person allo�ved to wark on you�-project. In these eircutnstal�ces,Miami Shores ti'�Ilage does not requi�•e veri�cation af
wot•kers' compensation insurance coverage from t}�e cant�-actor°s eompany for day labor,part-titne er��pioyees or subcc�tttraetors.
BY SfGNING �ELQVa� YQLT A�KNOVJLEDGE THAT YQU IIAVE READ TNIS NOTICE .AND C'�DERSTAND ITS
CCINTENTS. �`? `,
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Signature: `'�
�- ue __�— ���.'�--�
State of Florida
Cotiiity of Mia�ni-Dade
�
Tl�e foregoing�ras ackt�owledge before tr�e€�vs � � day°of � � � ��`�-�� �20 �-�
I3y���::-�:.���. ��'��-�.�.� � '�"��'��`�-������l�o is�ersonally k��a�u��to zne or l�as produeed
`�� ��w l?.: �,�`�_�����`��` asidetitif�cation.
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Faa�e (3Q5) 756.�972
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Fiorida Law reqt�ires Warkers' Compensatic�n insurance coverage u�zder Chapter 44Q af the Fiorida Statutes. Fla. Stat. § 44Q.QS
allaws corpe�rate affic�rs in the eanstnzction industry ta �xempt themselves frazn this requiren2ent for any canstru�tion projeot prior to
o�taining a building permit. Pursuant ta the Flarida Division af Workers'Compensation Empioycr FacGs Srachure:
iAn �mployer in the �onsEruction industry who �mplays ane or more partntir��e ar fuli-time
employ�es, ineluding the€�wner,rnust obtain workers' eampensat3on coverage. Corporate c�fficers
ar memb�rs of a limited Iiability company (LL,C} in the eanstrnctian iudustry �nay el�ct to be
exetnpti£
1. The officer owns at least 10 pereent of the stack of the carporation, or in the case of
an LLC,a statement attesting to the minimum 1 Q perc�nt ownership;
2. The affc�r is listed as an afficer c�f the corporation in the records af the Florida
( Department of State,Divislon of C'orporations,and
3. The cc�rparation is regisYered and listed as actiue with the Florida I)epartment af
State,L�ivisr`on of Corporations. �
I
No �nore than three corparate officers per carparatian Qr Iimi�ed liabiliry coin�any meml��rs are i
aliaw�d Eo be exetr�pt. Construction exemptions are valid F�r a period of two ye�rs c�r until a
valuntary revocatian is fil�d or th�exemption is revokec�by the Division.
Yaur contractar is rec�uesting a permit ttnder this warkers' �ompensatioa exemption and has acknowl�dg�that h�ar she wiil nat us�
day labar,�art�time�mployees or subcontractors for yacu-praject The contractor has provided an affidavit stating that he or she will
be the only person allawed to work on yc�ur proj�ct_Iz�these eircumstances,Miazni Shores Villag�daes not require verifieatican of
warkers' compensatian i�asuranc;e coverage fram the contractar's company for day labar,part-time ernpl�yees or suhcontractars.
BY SIGNING BELC}W YOU ACKN WI.ED�E THA`T YC3U HAVE READ THIS N�TIC� AItiID UNDEIiSTAND ITS
C(?NTENTS.
i
� Signaaare:
Stat�af Flarida
Caunty of Mia�i-Dad�
The forego'tng was acknowledge before me this �� day of�__C���"�-� ,20�.
By_��-�,( ��°1�„��� who is personaliy knawn to me or has produced
as identification.
Notary
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